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Sunday, August 18, 2013  
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Editor's Commentary - Jason J. Nichols, OD, MPH, PhD, FAAO

While we learn more and more about the tear film each year, it seems as though the more we learn, the more questions we ask. For instance, how do the tears stabilize after the blink? Are molecular changes responsible for the inability of the tears to stabilize? Lastly, how far have we developed our understanding of the tears and their ability to fight infection? Specifically, is there a link between ocular surface disease (dry eye) and risk for infection? While we have come a long way in our understanding of some of these things over the last 10 years, we still have a ways to go to get a more complete picture.

Diversified Launches New Website/Online Ordering Portal

Diversified Ophthalmics, Inc., along with its affiliates, MidSouth Premier Ophthalmics, Inc. and Firestone Optics, Inc., recently debuted its new website accessible at www.DivOpt.com or www.MSPremier.com. The new site, with features based on responses to customer survey requests, offers easier, more state-of-the-art navigation, and a wealth of resources and educational material about the wide range of products and services offered.

Each division of Diversified and its affiliates (wholesale lab, soft contact lenses, buying group, frames, gas permeable lenses, solutions & supplies, equipment, technology services, printing, office supplies, practice enrichment and Practice Maximus) has their own mini-website built into the new DivOpt.com.

In addition to its contemporary look, Diversified designed the site to be progressive in functionality as well. Some of the new features include a Press Release section, iCal Interactive Calendar, social media links with a Facebook feed to the home page, YouTube videos, and a Classifieds section. The site also has a secure server portal which provides protection for ordering and account information by the thousands of Diversified and MidSouth accounts.

DivOpt.com soft lens online ordering now offers four ways to place "Ship To Office" orders: grid ordering for ordering multiple powers of the same lens at once, patient ordering, stock ordering to quickly order lenses, and UPC ordering supporting UPC bar code scanning.

Future plans include merging the website of Firestone Optics, based in Kansas City, Missouri, which was acquired in January of this year.

SpecialEyes Joins Think About Your Eyes Eye Health Initiative
SpecialEyes, a custom contact lens company based in Sarasota, FL, recently signed on as a partner and financial supporter of the industry-wide initiative — Think About Your Eyes — to bring national awareness to the importance of eye health. Think About Your Eyes, L.L.C., a non-profit organization under The Vision Council and endorsed by the American Optometric Association, launched an aggressive consumer campaign in July designed to educate the public about the benefits of vision health and the importance of getting an annual comprehensive eye exam.

Think About Your Eyes is estimated to reach at least 120 million consumers through television, radio, print, online advertising, and social media engagement with strong educational and motivational messages focusing on eye disease, eye strain, kids' vision, and the positive impact of regular eye exams on overall health. Television spots will be seen on cable stations such as TBS, FX, NFL Network, and Nickelodeon, during primetime viewing hours as well as other timeslots throughout the day, while radio advertising will run during the peak drive time hours. Print ads will run in high-profile magazines such as People, Parents, and Sports Illustrated. Additional advertising will run as part of CNN's AccentHealth programming in primary care and pediatric offices.
To learn more about Think About Your Eyes, visit www.thinkaboutyoureyes.com. For more information on SpecialEyes please visit www.specialeyesqc.com.
Still Time to Submit GSLS Papers and Posters — Due by August 31
Plan now to attend the Global Specialty Lens Symposium to be held January 23 – 26, 2014 at the Rio All Suites Hotel and Casino in Las Vegas, Nevada. This meeting will include insightful presentations by international experts in the field, hands-on demonstrations of cutting-edge products and valuable continuing education credits.

The Program Committee of the GSLS invites the submission of Papers and Posters. Papers and abstracts related to presbyopia, keratoconus, corneal topography, post penetrating keratoplasty or related irregular corneal surface, myopia control, orthokeratology and lens care topics are welcome.

To submit a photo for the photo contest, submit up to two (2) photographic images in the following anterior segment categories: Contact Lens and Cornea/Conjunctiva/Lids. Contestants also will be able to submit images obtained utilizing such equipment as OCT, topographers, etc.

Visit www.GSLSymposium.com for more information. Web submissions only. Deadline for submissions is August 31, 2013.

Scleral Lens with Excessive Clearance
By Langis Michaud, OD, MSc, University of Montreal, Montreal, Canada

These are images of a 65 year-old Caucasian female with a cataract extraction after trauma. Her vision was corrected with scleral lenses fitted elsewhere. Patient complainted about blurred /double vision after a few hours of wear. She was seen after 5 hours of wear with a lot of mucus/debris in the fluid layer. OCT scan shows scattered debris and a big piece of mucus trapped Under the lens. VA was 20/200. Clearance was measured at 1000 microns. The patient went back to VA of 20/30 when the lens was rinsed and filled in with new saline. Cornea also showed edema. This illustrates that excessive clearance is not suitable in scleral lens fitting.

We thank Dr. Michaud for these images and we welcome photo submissions from our other readers! It is easy to submit a photo for consideration for publishing in Contact Lenses Today. Simply visit http://www.cltoday.com/upload/upload.aspx to upload your image. Please include an explanation of the photo and your full name, degree or title and city/state/country.

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Katherine M. Mastrota, MS, OD, FAAO

Dry Eye Symptoms and Pain Sensitivity

The August 2013 issue of Journal of the American Medical Association brings us a very interesting study exploring whether pain sensitivity plays a role in a patient's experience of dry eye disease (DED) symptoms. The authors remind us that although DED is common, little is known about factors contributing to its classic symptoms given the poor correlation between patient complaints and objective clinical signs. In this 1622 all-female study, 438 (27%) patients were categorized as having DED by OSDI. Quantitative sensory testing using heat stimulus on the forearm was used to assess pain sensitivity (heat pain threshold, HPT) and pain tolerance (heat pain supra-threshold, HPST). Women with DED showed a significantly lower HPT and HPST suggesting a higher pain sensitivity than those without DED. A strong significant association between the presence of pain symptoms on the OSDI and the HPT and HPST was found. The authors of this study suggest that high pain sensitivity and low pain tolerance are associated with symptoms of DED, adding to previous associations of the severity of tear insufficiency, cell damage, and psychological factors. Management of DED symptoms is complex, the authors conclude, and physicians need to consider the holistic picture, rather than simply treating ocular signs.1

Vehof J, Kozareva D, Hysi PG, Harris J, Nessa A, Williams FK, Bennett DL, McMahon SB, Fahy SJ, Direk K, Spector TD, Hammond CJ. Relationship Between Dry Eye Symptoms and Pain Sensitivity. JAMA Ophthalmol. 2013 Aug 1. [Epub ahead of print]
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Susan J. Gromacki, OD, MS, FAAO

How to Improve Patient Adherence to Your Contact Lens Wear and Care Instructions

In my last column,1 I reviewed an article that detailed patients' adherence/ compliance to their practitioner's treatment regimen.2 The paper also provides the authors' advice on how to improve patient adherence, specifically with regards to contact lens wear and care. The authors remind us that since there is very little research in this particular area; their evidence-based recommendations stem primarily from other health populations.

Here are their ideas:

  • Improve communication skills. Adherence rates are higher when physicians communicate well.3,4 The authors report that patients whose physicians received additional training in patient communication demonstrated greater adherence.
  • Take a patient-centered approach. Involving the patient in his/her healthcare decisions helps reinforce the recommendations.5
  • Ascertain compliance information by asking specific questions in a nonjudgmental way, in an effort to receive the most honest and accurate information.
  • Tailor your lens and lens care recommendations to your individual patient's needs and personality. (For example, if you don't think your patient will dispose of a one-day disposable contact lens daily, refrain from prescribing that lens. If you suspect that a patient will not use a daily cleaner, then don't prescribe lenses designed to last for 3 months or more; select a more disposable modality.)
1. http://www.cltoday.com/new/issue_080413.asp
2. Szabo MM, Enlow PT and Duncan CL. Understanding the psychology of non-adherence. Rev Corn CL 2013 June:14-17.
3. Zolnierek KBH, DiMatteo MR. Physician communication and patient adherence to treatment: a meta analysis. Med Care. 2009;47:826-834.
4. Nobile C, Drotar D. Research on the quality of parent-provider communication in pediatric care: implications and recommendations. J Dev Behav Pediatr. 2003;Aug 24(4):279-90.
5. Donovan JL. Patient decision making: the missing ingredient in compliance research. Int J Technol Assess Health Care. 1995;11:443-455.

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Antimicrobial Compounds in Tears

The tear film coats the cornea and conjunctiva and serves several important functions. It provides lubrication, prevents drying of the ocular surface epithelia, helps provide a smooth surface for refracting light, supplies oxygen and is an important component of the innate defense system of the eye providing protection against a range of potential pathogens. This review describes both classic antimicrobial compounds found in tears such as lysozyme and some more recently identified such as members of the cationic antimicrobial peptide family and surfactant protein-D, as well as potential new candidate molecules that may contribute to antimicrobial protection.

As is readily evident from the literature review herein, tears, like all mucosal fluids, contain a plethora of molecules with known antimicrobial effects. That all of these are active in vivo is debatable as many are present in low concentrations, may be influenced by other tear components such as the ionic environment, and antimicrobial action may be only one of several activities ascribed to the molecule. However, there are many studies showing synergistic/additive interactions between several of the tear antimicrobials and it is highly likely that cooperativity between molecules is the primary way tears are able to afford significant antimicrobial protection to the ocular surface in vivo. In addition to effects on pathogen growth and survival, some tear components prevent epithelial cell invasion and promote the epithelial expression of innate defense molecules. Given the protective role of tears, a number of scenarios can be envisaged that may affect the amount and/or activity of tear antimicrobials and hence compromise tear immunity. Two such situations, dry eye disease and contact lens wear, are discussed here.

McDermott AM. Antimicrobial compounds in tears. Exp Eye Res. 2013 Jul 20.

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